DOCSLIB.ORG

The Management of Bleeding from Anorectal Varices

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
The Management of Bleeding from Anorectal Varices Edinburgh Research Explorer The management of bleeding from anorectal varices Citation for published version: Robertson, M, Thompson, AI & Hayes, P 2017, 'The management of bleeding from anorectal varices', Current Hepatology Reports, vol. 16, no. 4. https://doi.org/10.1007/s11901-017-0382-6 Digital Object Identifier (DOI): 10.1007/s11901-017-0382-6 Link: Link to publication record in Edinburgh Research Explorer Document Version: Publisher's PDF, also known as Version of record Published In: Current Hepatology Reports General rights Copyright for the publications made accessible via the Edinburgh Research Explorer is retained by the author(s) and / or other copyright owners and it is a condition of accessing these publications that users recognise and abide by the legal requirements associated with these rights. Take down policy The University of Edinburgh has made every reasonable effort to ensure that Edinburgh Research Explorer content complies with UK legislation. If you believe that the public display of this file breaches copyright please contact [email protected] providing details, and we will remove access to the work immediately and investigate your claim. Download date: 25. Sep. 2021 Curr Hepatology Rep (2017) 16:406–415 https://doi.org/10.1007/s11901-017-0382-6 PORTAL HYPERTENSION (E TSOCHATZIS AND J ABRALDES, SECTION EDITORS) The Management of Bleeding from Anorectal Varices Marcus Robertson1,2 & Alexandra Ines Thompson1 & Peter Clive Hayes1 Published online: 7 November 2017 # The Author(s) 2017. This article is an open access publication Abstract alternative first-line treatments; all methods offer a technically Purpose of Review The purpose of this review is to summa- simple and efficacious method of achieving haemostasis, and rize available strategies for the diagnosis and management of local expertise will determine which procedure is employed. bleeding anorectal varices. Recent Findings Interventional radiological procedures, in- Keywords Anorectal varices . Endoscopy . Cirrhosis . Portal cluding TIPS, BRTO and/or embolization, have been hypertension . Band ligation . Sclerotherapy established as efficacious treatments, particularly in the setting of treatment failure. Summary Anorectal varices are prevalent in patients with por- Introduction tal hypertension. Acute bleeding is uncommon, but can be massive and life-threatening. Anorectal varices should be con- Variceal bleeding is a common and life-threatening manifes- sidered as a differential diagnosis in any patient with cirrhosis tation of portal hypertension and remains an important cause or portal hypertension who presents with lower gastrointesti- of death in patients with cirrhosis [1]. Esophago-gastric vari- nal bleeding. No evidence-based guidelines exist to guide the ces are by far the most common cause of acute variceal bleed- management of bleeding anorectal varices, which typically ing (AVB), the management of which is well-established and requires a multidisciplinary team of endoscopists, evidence-based. Ectopic varices are defined as dilated hepatologists, surgeons and interventional radiologists. portosystemic collateral veins occurring anywhere in the gas- Administration of prophylactic antibiotics and vasoactive trointestinal tract other than the esophago-gastric region and therapy is recommended based on efficacy in bleeding oe- include duodenal, jejunal, ileal, stomal, colonic and anorectal sophageal varices. Urgent endoscopy should be performed varices [2]. Ectopic varices constitute 2–5% of all variceal in all patients. Endoscopic sclerotherapy has the greatest body bleeds but are the cause of bleeding in 20–30% of patients of evidence and should be considered the first-line therapy; with extrahepatic portal hypertension [3–5]. Although rare, efficacy and safety may be increased if this is performed with acute ectopic variceal bleeding can be massive and life-threat- endoscopic ultrasound. Endoscopic banding or obturation are ening. The diagnosis and management of bleeding ectopic varices remains challenging, and their anatomical diversity Marcus Robertson and Alexandra Ines Thompson joint first-author makes development of standardized guidelines extremely difficult. This article is part of the Topical Collection on Portal Hypertension Anorectal varices represent portal-systemic collaterals * Peter Clive Hayes manifesting as discrete, dilated submucosal veins, extending [email protected] proximal to the dentate line and into the rectum [6]. Bleeding rectal varices typically present as hematochezia; an acute 1 Department of Hepatology, Royal Infirmary of Edinburgh, bleed from anorectal varices is rare but may result in life- Edinburgh, UK threatening haemorrhage. This review aims to summarize 2 Department of Gastroenterology, Monash Health, available strategies for the diagnosis and management of Melbourne, Australia bleeding anorectal varices. Curr Hepatology Rep (2017) 16:406–415 407 Pathophysiology, Aetiology and Prevalence endoscopic treatment of esophageal varices [23]. There is con- of Anorectal Varices flicting evidence regarding the occurrence of rectal varices following treatment of esophageal varices. Some studies have Portal hypertension is a well-recognized and common mani- suggested that injection sclerotherapy or band ligation of festation of chronic liver disease. In portal hypertension, a esophageal varices may influence the natural history of ectop- combination of increased splanchnic blood flow and ic varices. In the case of anorectal varices, this is postulated to intrahepatic resistance to portal blood flow leads to a patho- be due to development of collateral vessels in the inferior logical increase in portal pressures, which results in the devel- mesenteric venous system following obliteration of supplying opment of portosystemic collaterals, the most clinically sig- vessels (such as the left gastric, posterior gastric or short gas- nificant of which are gastroesophageal varices [7]. The hepatic tric veins) which ultimately leads to the formation of rectal venous pressure gradient (HVPG) is a useful clinical measure varices [11, 23, 24 ]. The correlation between treatment of of portal pressures and is defined as the gradient between the esophageal or gastric varices and subsequent formation of wedged hepatic venous pressure and the free hepatic venous anorectal varices has not been conclusively demonstrated. pressure [8–10]. The HVPG can be used to risk stratify pa- Despite the high prevalence of anorectal varices, massive tients with portal hypertension, although in practice it is not haemorrhage remains an uncommon event and studies report frequently performed due to the invasiveness of the procedure. a frequency ranging from 0.5 to 3.6% [25]. The prevalence of The normal HVPG ranges between 1 and 5 mmHg and a haemorrhage from anorectal varices is significantly increased portal pressure gradient of ≥ 12 mmHg is well established as in larger varices and in patients with high-risk stigmata such as the baseline elevated pressure above which variceal develop- a positive “red colour” sign [26]. There is no evidence to ment and bleeding may occur. suggest that the incidence of bleeding is increased with the Anorectal varices represent porto-systemic collateral ves- presence of oesophageal variceal bleeding, a history of previ- sels that constitute a pathway for portal venous blood flow ous treatment of oesophageal varices or the aetiology of portal between the superior rectal veins of the inferior mesenteric hypertension [6, 26]. system and the middle inferior rectal veins of the iliac system [2, 11, 12]. They manifest as dilated and engorged submucosal veins in the rectum [6]. Anorectal varices most commonly Clinical Presentation, Diagnosis and Evaluation result from portal hypertension secondary to cirrhosis [13]. of Anorectal Varices A variety of conditions that result in non-cirrhotic portal hy- pertension are also associated with the development of Bleeding anorectal varices most commonly presents as anorectal varices [14], including mesenteric [15–17]orsplen- hematochezia (bleeding per rectum), which is typically acute ic vein obstruction [18] from carcinoid syndrome or pancrea- or chronic recurrent. The diagnosis of anorectal varices is titis respectively, along with cavernous malformation of the usually made at endoscopy (Fig. 1); however, endoscopic ul- portal vein. In addition, systemic conditions such as conges- trasound (EUS) and imaging have also been employed. tive heart failure or congenital vascular anomalies have been postulated as potential causes of anorectal varices [6]. Endoscopy The incidence of anorectal varices varies widely between studies, ranging from 38 to 95% [19, 20]. In patients with Diagnosis of anorectal variceal bleeding is primarily achieved established liver cirrhosis, prevalence ranges from 38 to at endoscopy (either flexible sigmoidoscopy or colonoscopy) 92% [19, 21]. Multiple studies have suggested a higher prev- [25], which remains the gold-standard investigation. alence of anorectal varices in patients with non-cirrhotic portal Anorectal varices typically appear as blue-tinted, serpentine, hypertension or extra-hepatic portal vein obstruction (63– sub-mucosal varicose veins located near the anus, which al- 95%) and varices were significantly larger in this cohort [19, ways cross the dentate line to extend cranially and can also 20]; no identifiable causes have been found to explain these extend into the rectum [6, 11, 22]. Diagnosis can be difficult in differences [6].
Load more

Recommended publications
  • General Signs and Symptoms of Abdominal Diseases
    General signs and symptoms of abdominal diseases Dr. Förhécz Zsolt Semmelweis University 3rd Department of Internal Medicine Faculty of Medicine, 3rd Year 2018/2019 1st Semester • For descriptive purposes, the abdomen is divided by imaginary lines crossing at the umbilicus, forming the right upper, right lower, left upper, and left lower quadrants. • Another system divides the abdomen into nine sections. Terms for three of them are commonly used: epigastric, umbilical, and hypogastric, or suprapubic Common or Concerning Symptoms • Indigestion or anorexia • Nausea, vomiting, or hematemesis • Abdominal pain • Dysphagia and/or odynophagia • Change in bowel function • Constipation or diarrhea • Jaundice “How is your appetite?” • Anorexia, nausea, vomiting in many gastrointestinal disorders; and – also in pregnancy, – diabetic ketoacidosis, – adrenal insufficiency, – hypercalcemia, – uremia, – liver disease, – emotional states, – adverse drug reactions – Induced but without nausea in anorexia/ bulimia. • Anorexia is a loss or lack of appetite. • Some patients may not actually vomit but raise esophageal or gastric contents in the absence of nausea or retching, called regurgitation. – in esophageal narrowing from stricture or cancer; also with incompetent gastroesophageal sphincter • Ask about any vomitus or regurgitated material and inspect it yourself if possible!!!! – What color is it? – What does the vomitus smell like? – How much has there been? – Ask specifically if it contains any blood and try to determine how much? • Fecal odor – in small bowel obstruction – or gastrocolic fistula • Gastric juice is clear or mucoid. Small amounts of yellowish or greenish bile are common and have no special significance. • Brownish or blackish vomitus with a “coffee- grounds” appearance suggests blood altered by gastric acid.
    [Show full text]
  • Editorial Has the Time Come for Cyanoacrylate Injection to Become the Standard-Of-Care for Gastric Varices?
    Tropical Gastroenterology 2010;31(3):141–144 Editorial Has the time come for cyanoacrylate injection to become the standard-of-care for gastric varices? Radha K. Dhiman, Narendra Chowdhry, Yogesh K Chawla The prevalence of gastric varices varies between 5% and 33% among patients with portal Department of Hepatology, hypertension with a reported incidence of bleeding of about 25% in 2 years and with a higher Postgraduate Institute of Medical bleeding incidence for fundal varices.1 Risk factors for gastric variceal hemorrhage include the education Research (PGIMER), size of fundal varices [more with large varices (as >10 mm)], Child class (C>B>A), and endoscopic Chandigarh, India presence of variceal red spots (defined as localized reddish mucosal area or spots on the mucosal surface of a varix).2 Gastric varices bleed less commonly as compared to esophageal Correspondence: Dr. Radha K. Dhiman, varices (25% versus 64%, respectively) but they bleed more severely, require more blood E-mail: [email protected] transfusions and are associated with increased mortality.3,4 The approach to optimal treatment for gastric varices remains controversial due to a lack of large, randomized, controlled trials and no clear clinical consensus. The endoscopic treatment modalities depend to a large extent on an accurate categorization of gastric varices. This classification categorizes gastric varices on the basis of their location in the stomach and their relationship with esophageal varices.1,5 Gastroesophageal varices are associated with varices along
    [Show full text]
  • Chapter 156: Upper Gastrointestinal Bleeding
    8/23/2018 Principles and Practice of Hospital Medicine, 2e > Chapter 156: Upper Gastrointestinal Bleeding Stephen R. Rotman; John R. Saltzman INTRODUCTION Key Clinical Questions What is the timing and treatment of peptic ulcer disease? What are the factors in diagnosis and treatment of aortoenteric fistula? What treatments are available for each etiology of upper GI bleeding? What is the appropriate management and follow-up of variceal bleeding? How do you estimate the severity of bleeding so that you can triage appropriate patients to the ICU, medical floor, or observation unit? Which patients are more likely to rebleed and hence require continued observation in the hospital aer their bleeding has apparently stopped, and for how long? Upper gastrointestinal (GI) bleeding is responsible for over 300,000 hospitalizations per year in the United States. An additional 100,000 to 150,000 patients develop upper GI bleeding during hospitalizations. The annual cost of treating nonvariceal acute upper GI bleeding in the United States exceeds $7 billion. Upper GI bleeding is defined as a bleeding source in the GI tract proximal to the ligament of Treitz. The presentation varies depending on the nature and severity of bleeding and includes hematemesis, melena, hematochezia (in rapid upper GI bleeding), and anemia with heme-positive stools. Bleeding can be associated with changes in vital signs, including tachycardia and hypotension including orthostatic hypotension. Given the range of presentations, pinpointing the nature and severity of GI bleeding may be a challenging task. The natural history of nonvariceal upper GI bleeding is that 80% of patients will stop bleeding spontaneously and no further urgent intervention will be needed.
    [Show full text]
  • Overview of Esophageal and Gastric Varices
    pISSN 2287-2728 eISSN 2287-285X https://doi.org/10.3350/cmh.2020.0022 Review Clinical and Molecular Hepatology 2020;26:444-460 Managing liver cirrhotic complications: Overview of esophageal and gastric varices Cosmas Rinaldi Adithya Lesmana1,2, Monica Raharjo1, and Rino A. Gani1 1Division of Hepatobiliary, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta; 2Digestive Disease & GI Oncology Centre, Medistra Hospital, Jakarta, Indonesia Managing liver cirrhosis in clinical practice is still a challenging problem as its progression is associated with serious complications, such as variceal bleeding that may increase mortality. Portal hypertension (PH) is the main key for the development of liver cirrhosis complications. Portal pressure above 10 mmHg, termed as clinically significant portal hypertension, is associated with formation of varices; meanwhile, portal pressure above 12 mmHg is associated with variceal bleeding. Hepatic vein pressure gradient measurement and esophagogastroduodenoscopy remain the gold standard for assessing portal pressure and detecting varices. Recently, non-invasive methods have been studied for evaluation of portal pressure and varices detection in liver cirrhotic patients. Various guidelines have been published for clinicians’ guidance in the management of esophagogastric varices which aims to prevent development of varices, acute variceal bleeding, and variceal rebleeding. This writing provides a comprehensive review on development of PH and varices in liver cirrhosis patients and its management based on current international guidelines and real experience in Indonesia. (Clin Mol Hepatol 2020;26:444-460) Keywords: Liver cirrhosis; Hypertension, Portal; Esophageal and gastric varices INTRODUCTION tes, hepatic encephalopathy, coagulation dysfunction, hepatorenal syndrome, and even cardiac and pulmonary complications.
    [Show full text]
  • Diagnosis and Management of Ectopic Varices
    Gastrointest Interv 2012; 1:3–10 Contents lists available at SciVerse ScienceDirect Gastrointestinal Intervention journal homepage: www.gi-intervention.org Review Article Diagnosis and management of ectopic varices Nabeel M. Akhter, Ziv J. Haskal* abstract Ectopic varices are large portosystemic collaterals in locations other than the gastroesophageal region. They account for up to 5% of all variceal bleeding; however, hemorrhage can be massive with mortality reaching up to 40%. Given their sporadic nature, literature is limited to case reports, small case series and reviews, without guidelines on management. As the source of bleeding can be obscure, the physician managing such a patient needs to establish diagnosis early. Multislice computed tomography with contrast and reformatted images is a rapid and validated modality in establishing diagnosis. Further management is dictated by location, underlying cause of ectopic varices and available expertise. Therapeutic options may include double balloon enteroscopy, transcatheter embolization or sclerotherapy, with or without portosystemic decompression, i.e., transjugular intrahepatic portosystemic shunts. In this article we review the prevalence, etiopathogenesis, anatomy, presentation, and diagnosis of ectopic varices with emphasis on recent advances in management. Copyright Ó 2012, Society of Gastrointestinal Intervention. Published by Elsevier. All rights reserved. Keywords: Balloon-occluded retrograde transvenous obliteration, Ectopic varices, Portal hypertension, Percutaneous embolization,
    [Show full text]
  • Palliative Care in Advanced Liver Disease (Marsano 2018)
    Palliative Care in Advanced Liver Disease Luis Marsano, MD 2018 Mortality in Cirrhosis • Stable Cirrhosis: – Prognosis determined by MELD-Na score – Provides 90 day mortality. – http://www.mdcalc.com/meldna-meld-na-score-for-liver-cirrhosis/ • Acute on Chronic Liver Failure (ACLF) – Mortality Provided by CLIF-C ACLF Calculator – Provides mortality at 1, 3, 6 and 12 months. – http://www.clifresearch.com/ToolsCalculators.aspx • Acute Decompensation (without ACLF): – Mortality Provided by CLIF-C Acute decompensation Calculator – Provides mortality at 1, 3, 6 and 12 months. – http://www.clifresearch.com/ToolsCalculators.aspx • Survival of Ambulatory Patients with HCC (MESIAH) – Provides survival at 1, 3, 6, 12, 24 and 36 months. – https://www.mayoclinic.org/medical-professionals/model-end-stage-liver- disease/model-estimate-survival-ambulatory-hepatocellular-carcinoma-patients- mesiah Acute Decompensation Type and Mortality Organ Failure in Acute-on-Chronic Liver Failure Organ Failure Mortality Impact Frequency of Organ Failure 48% have >/= 2 Organ Failures The MESIAH Score Model of Estimated Survival In Ambulatory patients with HCC Complications of Cirrhosis Affecting Palliative Care • Ascites and Hepatic Hydrothorax. • Hyponatremia. • Hepatorenal syndrome. • Hepatic Encephalopathy. • Malnutrition/ Anorexia. • GI bleeding: Varices, Portal gastropathy & Gastric Antral Vascular Ectasia • Pruritus • Hepatopulmonary Syndrome. Difficult Decisions with Shifting Balance • Is patient a liver transplant candidate? • Effect of illness in: – patient’s survival – patient’s Quality of Life • patient’s relation to family • family’s Quality of Life • Effect of therapy in: – patient’s survival – patient’s Quality of Life • patient’s relation to family • family’s Quality of life Ascites and Palliation • PATHOGENESIS • CONSEQUENCES • Hepatic sinusoidal HTN • Abdominal distention with early stimulates hepatic satiety.
    [Show full text]
  • Insights Into the Management of Anorectal Disease in the Coronavirus 2019 Disease Era
    University of Massachusetts Medical School eScholarship@UMMS COVID-19 Publications by UMMS Authors 2021-07-09 Insights into the management of anorectal disease in the coronavirus 2019 disease era Waseem Amjad Albany Medical Center Et al. Let us know how access to this document benefits ou.y Follow this and additional works at: https://escholarship.umassmed.edu/covid19 Part of the Digestive System Diseases Commons, Gastroenterology Commons, Infectious Disease Commons, Telemedicine Commons, and the Virus Diseases Commons Repository Citation Amjad W, Haider R, Malik A, Qureshi W. (2021). Insights into the management of anorectal disease in the coronavirus 2019 disease era. COVID-19 Publications by UMMS Authors. https://doi.org/10.1177/ 17562848211028117. Retrieved from https://escholarship.umassmed.edu/covid19/285 Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 License This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in COVID-19 Publications by UMMS Authors by an authorized administrator of eScholarship@UMMS. For more information, please contact [email protected]. TAG0010.1177/17562848211028117Therapeutic Advances in GastroenterologyW Amjad, R Haider 1028117research-article20212021 Advances and Future Perspectives in Colorectal Cancer Special Collection Therapeutic Advances in Gastroenterology Review Ther Adv Gastroenterol Insights into the management of anorectal 2021, Vol. 14: 1–13 https://doi.org/10.1177/17562848211028117DOI: 10.1177/ disease in the coronavirus 2019 disease era https://doi.org/10.1177/1756284821102811717562848211028117 © The Author(s), 2021. Article reuse guidelines: Waseem Amjad, Rabbia Haider, Adnan Malik and Waqas T. Qureshi sagepub.com/journals- permissions Abstract: Coronavirus 2019 disease (COVID-19) has created major impacts on public health.
    [Show full text]
  • Massive Gastric Variceal Hemorrhage Due to Splenic Vein Thrombosis
    Journal of Liver Research, Disorders & Therapy Case Report Open Access Massive gastric variceal hemorrhage due to splenic vein thrombosis; a rare initial presentation of asymptomatic metastatic pancreatic adenocarcinoma Introduction Volume 4 Issue 3 - 2018 Isolated sinistral portal hypertension (SPH) is extremely rare, 1,2 representing less than 5% of all portal hypertension cases. Splenic Kelley Nguyen,1 Daniel S Zhang,2 Mark A vein thrombosis is typically discovered incidentally on imaging and Sultenfuss,3 David W Victor III2 is often asymptomatic. Variceal bleeding can ensue in SPH, which 1Texas A&M University College of Medicine, USA develops due to increased pressure on the left side of the portal system.3 2Department of Medicine, Section of Gastroenterology and While most gastric varices are caused by cirrhotic portal hypertension, Hepatology, Methodist Hospital, USA rare cases occur due to non-cirrhotic splenic venous thrombosis. Here, 3Department of Radiology, Methodist Hospital, USA we present massive gastric variceal bleeding splenic vein thrombosis as the initial presentation of pancreatic adenocarcinoma. Correspondence: David Victor III, Associate Professor of Clinical Medicine, Weill-Cornell Medical College, Section of Case report Hepatology & Transplant Medicine, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston A 71-year old man presented to the emergency department with Methodist J.C. Walter , Transplant Center, Houston Methodist acute onset massive hematemesis and epigastric pain. He denied Hospital, 6550, annin St., Ste 1201 Houston, TX 77030, USA, Tel jaundice, NSAID use or prior hematemesis. Relevant medical 7134-4133-72, Email [email protected] history included heavy tobacco use in the past but denied alcohol Received: June 18, 2018 | Published: June 25, 2018 use.
    [Show full text]
  • Journal of Gastroenterology and Hepatology Research
    Journal of Gastroenterology and Hepatology Research Online Submissions: http://www.ghrnet.org/index./joghr/ Journal of GHR 2015 February 21 4(2): 1478-1480 doi:10.6051/j.issn.2224-3992.2015.04.501 ISSN 2224-3992 (print) ISSN 2224-6509 (online) CASE REPORT Successful Endoscopic Treatment of Bleeding Anorectal Varices in a Patient with Advanced Pancreatic Cancer Masayuki Nakanowatari, Takahiro Sato, Michio Iida, Jiro Honma, Takashi Fukuhara Masayuki Nakanowatari, Michio Iida, Jiro Honma, Takashi with Advanced Pancreatic Cancer. Journal of Gastroenterology and Fukuhara, Department of Palliative Care Medicine, Sapporo Kosei Hepatology Research 2015; 4(2): 1478-1480 Available from: URL: General Hospital, Kita3 Higashi8-5, Chuo-ku, Sapporo, Hokkaido http://www.ghrnet.org/index.php/joghr/article/view/963 060-0033, Japan Takahiro Sato, Department of Gastroenterology, Sapporo Kosei INTRODUCTION General Hospital, Kita3 Higashi8-5, Chuo-ku, Sapporo, Hokkaido Anorectal varices due to an extra-hepatic portal vein obstruction 060-0033, Japan (EHO) are rare in patients with portal hypertension. The occurrence Correspondence to: Masayuki Nakanowatari, MD, Department [1,2] of rectal varices varies among different reports (3.6-9%) , of Palliative Care Medicine, Sapporo Kosei General Hospital, Kita3 accounting for 10% or less of patients with portal hypertension. Higashi8-5, Chuo-ku, Sapporo, Hokkaido 060-0033, Japan. According to a nationwide survey of ectopic varices in Japan from Email: [email protected] 2001 to 2005, rectal varices were the most common type of ectopic Telephone: +81-11-261-5331 Fax: +81-11-271-5320 [3] varices; the number of patients with rectal varices was 77 .
    [Show full text]
  • Esophageal Varices
    World Gastroenterology Organisation Global Guidelines Esophageal varices JANUARY 2014 Revision authors Prof. D. LaBrecque (USA) Prof. A.G. Khan (Pakistan) Prof. S.K. Sarin (India) Drs. A.W. Le Mair (Netherlands) Original Review team Prof. D. LaBrecque (Chair, USA) Prof. P. Dite (Co-Chair, Czech Republic) Prof. Michael Fried (Switzerland) Prof. A. Gangl (Austria) Prof. A.G. Khan (Pakistan) Prof. D. Bjorkman (USA) Prof. R. Eliakim (Israel) Prof. R. Bektaeva (Kazakhstan) Prof. S.K. Sarin (India) Prof. S. Fedail (Sudan) Drs. J.H. Krabshuis (France) Drs. A.W. Le Mair (Netherlands) © World Gastroenterology Organisation, 2013 WGO Practice Guideline Esophageal Varices 2 Contents 1 INTRODUCTION ESOPHAGEAL VARICES............................................................. 2 1.1 WGO CASCADES – A RESOURCE -SENSITIVE APPROACH ............................................. 2 1.2 EPIDEMIOLOGY ............................................................................................................ 2 1.3 NATURAL HISTORY ...................................................................................................... 3 1.4 RISK FACTORS .............................................................................................................. 4 2 DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS...................................................... 5 2.1 DIFFERENTIAL DIAGNOSIS OF ESOPHAGEAL VARICES /HEMORRHAGE ......................... 5 2.2 EXAMPLE FROM AFRICA — ESOPHAGEAL VARICES CAUSED BY SCHISTOSOMIASIS .. 6 2.3 OTHER CONSIDERATIONS ............................................................................................
    [Show full text]
  • Luis S. Marsano, MD, FACG, FASGE, AGAF, FAASLD
    Luis S. Marsano, MD, FACG, FASGE, AGAF, FAASLD Professor of Medicine Division of Gastroenterology, Hepatology & Nutrition University of Louisville and Louisville VAMC 2018 Magnitude of the Problem Incidence: 36-100 per 170,000 persons 40% > 60 years old Self limited in 80% EGD in < 24 hours done in 90% Endoscopic hemostasis done in 25% Mortality: 10,000 to 20,000 per year Overall: 14 % (10-36%) Admission for GI bleed: 11 % mortality GI bleed in the hospitalized: 33 % mortality Timing of EGD (“< 6 h”, VS. “within 48 h”) (Gastrointestinal Endoscopy 2004; 60:1-8) : No effect in transfusion needs nor LOS No effect on need for surgery No effect on mortality More “high risk” lesions found on early EGD good for training & may decrease re-bleeding rate. Hematemesis: bleed above ligament of Treitz. Red blood emesis, or Coffee ground emesis Melena: may be upper or lower source > 200 mL blood in stomach, or Up to 150 mL blood in cecum) Hematochezia: - usually lower source; 11% from upper source. Needs > 1000 mL blood from upper source Upper orthostatic @ 3 min: BPs drop =/> 10 mmHg and/or HR increase > 20 bpm. > 150 mL blood in Right colon, or > 100 mL blood in Left colon. 50% of bleedings from duodenal lesion have (-) NGT aspirate (Gastrointest Endosc 1981;27:94-103) Compared with endoscopy, NGT aspirate detects UGI bleeding with (Arch Intern Med 1990;150:1381-4) : 79% Sensitivity & 55% Specificity. Clear or bilious aspirate: 14% have high-risk lesions (Gastrointest Endosc 2004;59:172-8). Aspirate of blood: 42% have “clean base” or “pigmented spot”.
    [Show full text]
  • Adverse Events of Upper GI Endoscopy
    GUIDELINE Adverse events of upper GI endoscopy This is one of a series of statements discussing the use of lications rely on self-reporting, and most reported data GI endoscopy in common clinical situations. The Stan- collected only from the immediate periprocedure period, dards of Practice Committee of the American Society for thus the rate of late adverse events and mortality may be Gastrointestinal Endoscopy (ASGE) prepared this text. underestimated.8,9 Major adverse events related to diag- In preparing this document, a search of the medical liter- nostic UGI endoscopy are rare and include cardiopulmo- ature was performed by using PubMed. Additional refer- nary adverse events, infection, perforation, and bleeding. ences were obtained from the bibliographies of the identi- Adverse events of ERCP and EUS are discussed in separate fied articles and from recommendations of expert ASGE documents.10,11 consultants. When few or no data exist from well-designed prospective trials, emphasis is given to results of large series and reports from recognized experts. This document is ADVERSE EVENTS ASSOCIATED WITH based on a critical review of the available data and expert DIAGNOSTIC UGI ENDOSCOPY consensus at the time that the document was drafted. Further controlled clinical studies may be needed to clar- Cardiopulmonary adverse events ify aspects of this document. This document may be re- Most UGI procedures in the United States and Europe vised as necessary to account for changes in technology, are performed with patients under sedation (moderate or 12 new data, or other aspects of clinical practice. deep). Cardiopulmonary adverse events related to seda- This document is intended to be an educational device tion and analgesia account for as much as 60% of UGI 1-4,7 to provide information that may assist endoscopists in endoscopy adverse events.
    [Show full text]